Medication errors represent a significant source of patient harm, and patients with mental health diagnoses may be particularly vulnerable. This systematic review found that medication errors and adverse drug events in mental health hospitals are common.

Clinical Guideline

Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.

Journal Article > Commentary

High-alert medications are associated with adverse drug events and patient harm. Information technologies such as clinical alert systems can help with medication management. This commentary discusses how alerting systems can improve prescribing of high-alert medications and reviews factors that institutions should consider to successfully implement such systems.

Tools/Toolkit > Government Resource

This survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies. The data collection process for the latest national comparison is now closed.

Journal Article > Study

Inaccurate dosing of liquid medications for pediatric patients is known to contribute to medication errors. In this randomized controlled trial, parents of children younger than 9 were able to demonstrate a correct liquid medication dose when they received a dosing tool, such as a syringe, that corresponded more closely to the prescribed medication volume. Directions that include a picture were more likely to lead to accurate dosing compared to text-only instructions. This study adds to prior research demonstrating the need for literacy-friendly medication instructions, especially for dosing of liquid medications to children. Two of the coauthors, Michael S. Wolf and Stacy C. Bailey, described the implications of limited health literacy on patient safety in a past PSNet perspective.

Care transitions increase risk for medication errors. This meta-analysis found that pharmacist support during care transitions reduced medication errors and postdischarge emergency department visits. These results support a role for pharmacists in medication safety interventions for patients undergoing care transitions.

This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.

Newspaper/Magazine Article

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Newspaper/Magazine Article

According to this analysis of more than 1000 reports of errors occurring in community pharmacies, more than half reached the patient. Common error types included wrong drug and wrong dose incidents. Counseling patients on their medications at the point of sale can improve the reliability of outpatient pharmacy practice.

Patient Safety Primers

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients, and preventing ADEs is a major priority for accrediting bodies and regulatory agencies. Medication errors can occur at any stage of the medication use pathway, and a growing evidence base supports specific strategies to prevent ADEs.

Journal Article > Review

This narrative review examined the incidence of adverse symptoms arising from self-administration of over-the-counter medications and formerly prescribed medications among older adults. The literature suggests that self-administration of medications is common and often leads to adverse drug events. The authors call for prospective studies to better characterize this patient safety issue.

An accurate list of patient medications is a necessary precursor for safe medication use. One strategy to improve medication reconciliation is to provide a list of dispensed outpatient medications to inpatient clinicians upon hospital admission via an electronic medication reconciliation process. This retrospective chart review study compared a research pharmacist–generated gold standard medication list to the actual medications ordered during an admission after such a process was implemented. The study team identified medication discrepancies between the pharmacist-generated and admission-ordered medication lists and noted any inappropriately prescribed or continued medications. Medication errors were present in nearly half of the patient records; about 9% of errors were clinically important. The authors raise concerns that electronically prepopulated medication reconciliation forms may actually adversely impact medication safety. A previous WebM&M commentary discussed how to enhance accuracy of medication reconciliation.

Journal Article > Study

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Special or Theme Issue

Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this special issue explore polypharmacy in a variety of care settings and provide tactics for improvement, such as enhancing care integration for older patients through medication reconciliation and deprescribing initiatives.

Web Resource > Multi-use Website

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. This website provides information about a worldwide effort to improve medication safety by examining elements of medication prescription, distribution, and use that are vulnerable. The campaign will highlight best practices to address these weaknesses.

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.